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Whatever else, arguments for and against assisted dying must include the notion of cruelty. In my view there can be little more cruel than to decline the request for help in, or advice on, dying from patients of sound mind, who are competent to make decisions, who are suffering unbearably from a disabling disease for which there is no prospect of improvement, and who have made it clear that they no longer wish to live. On grounds of cruelty alone, we as doctors should be campaigning for change, for the introduction of laws that permit us to assist. Yet overall as individuals there seems little interest in the fight, while our leading medical organisations (British Medical Association, Royal College of General Practitioners, Royal Society of Medicine, Royal College of Physicians) actively oppose change.

For me, this all seems to suggest that doctors are institutionally, and all too often individually, cruel, and certainly there is evidence for this in our history. As a doctor I have been witness to, and in some instances involved in, behaviour that was unquestionably cruel. I well remember how teams of us (nurses included) would forcibly restrain (grapple with and hold down) resistant (‘difficult’) patients to introduce a gastric tube in order to wash out tablets taken in overdose. Committing suicide was then illegal and instructions to carry out gastric lavage were followed without a second thought. Our behaviour was quite horrible, but was justified by those in the medical profession who took the we-know-best position, and argued we were being ‘cruel to be kind’. Others will have taken the ‘sanctity of life’ position, arguing that above all else, life must be saved. Whatever the defence, nowadays forcefully washing out the stomach in this way would be unthinkable.

One might suppose that the assault of patients who had taken an overdose was an isolated example of cruelty but not so, after all, doctors were similarly involved in force-feeding prisoners on hunger strike. In another example cruelty was seen with the introduction of law to permit abortion. Here change was driven by public pressure rather than by medical foresight, and against which there was actually opposition from at least two of the Royal Colleges. Remember too our treatment of patients with intractable pain. There was none of the modern idea of giving analgesics to prevent pain developing. In those old (more puritanical) days, it was not uncommon for patients to be given their analgesia once the pain was intolerable and then only when they asked (sometimes begged!) for it – a relationship that was both cruel and demeaning. And in a much smaller way this still goes on. It hurts a lot when an artery is punctured but this can easily be prevented by injecting local anaesthetic around the vessel. At present such prophylaxis is rarely used leaving patients to ‘grin and bear it’.

Examples of cruel (demeaning) behaviour do not stop here once one recognises that cruelty does not necessarily involve physical hurt. Not so long ago, and in the face of questioning, doctors routinely withheld from patients the details of their diagnosis (as, for instance, a cancer), the names of their medicines, and their results. And of course medical students were famously encouraged to undertake intimate examinations without permission while patients were anaesthetised. But these have changed as society has demanded that we look at ourselves and re-evaluate our practice.

But now to the substantive point. The kindest, most humane, most compassionate response to (‘legitimate’) requests for help in dying would be for doctors to aid patients, helping them have a dignified death at a time and place of their convenience. Death is a natural and inevitable part of the human condition, and for determined patients who want to end their lives, the alternative to assisted dying is to use their own devices. This, as with the old ‘back street abortion’, simply serves to make their end squalid, risky, and undignified. We should note how, in retrospect, the cruel behaviours we practised in the past are now seen as totally unacceptable. One day, the current practice whereby we deny people help in dying will be seen in the same way. On grounds of cruelty alone, we as doctors should be fighting to decriminalise assistance in dying.

This blog is based on one first published for a lay readership in greyhares.org

Joe Collier is emeritus professor of medicines policy at St George’s, University of London

Thank you Professor Collier for such an article. As both a post graduate student in public health and a patient with chronic illness, I also believe that assistance in dying is necessary. In general, Western society is a death denying culture and only through appropriate education will people begin to understand that the prolongation of life is not equivalent to quality of life. Assistance in dying or euthanasia, not only allows the patient control over their final life decision, but also as you noted gives the patient dignity. Patients with terminal and chronic illness ought be able to make an informed choice regarding assisted dying.

Simon Kenwright

There have always been callous and cruel doctors but they are only one end of a professional spectrum that still includes much compassion. The problem is that we have not learnt when enough is enough ,even well short of assisted dying. We have also come to see the relief of distress as the job of someone else rather than seeing that someone else as someone with additional skills. I retired a few years ago , but there were clearly pressures not to give adequate sedation or analgaesia even to those who were dying but required invasive procedures. What was needed was adequate training in how to use these drugs not a relative embargo. One of the most iniquitous trends in those who are opposed to assisted dying is the overemphasis being placed on the possibility that some dying patients might be under pressure or see themselves as a burden. Of course this needs to be considered , but intrinsic to this objection is the rider that this group of patients should not be allowed to refuse medical interventions if these might prolong life. The importance of this right of refusal is one of the reasons why I continue to be a member of Dignity in Dying . Those dying patients who do refuse treatment should also be allowed whatever symptom relief is needed . Clause 15 in one of the earlier versions of the Joffe Bill on assisted dying stated a “patient suffering from a terminal illness shall be entitled to request and receive such medication as may be necessary to keep him free as far as possible from pain and distress”. It was largely in response to objections from the medical profession that the clause was withdrawn.

Daniel Cox

Thank you for your thought provoking blog. However, this is an issue with a greater depth of complexity than has been alluded to. Of course the Royal Colleges & the BMA run a mile from progress in this debate, as at its heart, policies which allow for assisted dying intractably incorporate the idea that a doctor will have to make a judgement on the value of another person’s life.

This blog has focussed on the idea that we should help people to die because it’s cruel not to. But how do we know it’s cruel? There are only two possible sources of evidence from which we can draw: a) Subjective – the patient feels that their life is intolerably painful or b) Objective – we feel it must be so.

I read the blog above (perhaps incorrectly) as alluding to the idea that we should respect evidence from option a)…if the patient says it’s cruel to prolong their life, then it is i.e. respect (a rather ‘thin’ version of) their autonomous choice. However, what if a patient (age 26) came to you as a Dr. and said that philosophically they could give you a rational reason as to why they should not go on living, a reason which included the avoidance of future pain and that the thought of prolonging life was excruciating to them. Although they were eminently physically healthy – the inner pain they suffered from this belief was intractable. Were it legal, morally should we help them to die? I think not. Although we can be no more sure that they are not experiencing cruel levels of inner pain than anyone else than other physically unwell patients.

It is for this reason that Dr.’s would have to, were it legal, make judgements on the value of a patient’s life before assisting them in leaving it. And this truth forms the basis of why society and medical organisations tread carefully near this topic. Is it right for Drs. to make judgements on the quality of people’s lives? How would the public feel about this? What supernatural power do we possess to know how intolerable or valuable someone’s life has become?